Transitions of Care

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Transitions of Care

• www.ntocc.org

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What is Transition of Care

• The movement of patients from one health care
  practitioner or setting to another as their
  condition and care needs change
• Occurs at multiple levels
• Within Settings
• Primary care ? Specialty care
• ICU ? Ward
• Between Settings
• Hospital ? Sub-acute facility
• Ambulatory clinic ? Senior center
• Hospital ? Home
• Across health states
• Curative care ? Palliative care/Hospice
• Personal residence ? Assisted living

(c) Eric A. Coleman, MD, MPH
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What is Transitional Care?

• A set of actions designed to ensure the
  coordination and continuity of health care as
  patients transfer between different locations or
  different levels of care within the same location
• Based on a comprehensive care plan and
  availability of well-trained practitioners that
  have current information about the patient's
  goals, preferences, and clinical status.
• Includes
• Logistical arrangements
• Education of the patient and family
• Coordination among the health professionals
  involved in the transition

Coleman EA, Boult C, The American Geriatrics
Society Health Care Systems Committee. J Am
Geriatr Soc 200351556-7.
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Ineffective Transitions Lead to Poor Outcomes

• Wrong treatment
• Delay in diagnosis
• Severe adverse events
• Patient complaints
• Increased healthcare costs
• Increased length of stay

Australian Council for Safety and Quality in
Health Care. Clinical hand-over and Patient
Safety literature Review Report. March 2005.
Available www.safetyandquality.org/internet/safety
/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0
081CD95/File/clinhovrlitrev.pdf
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Problems That Illustrate Inadequacies of Care
Transitions

• Medication errors
• Increased health care utilization
• Inefficient/duplicative care
• Inadequate patient/caregiver preparation
• Inadequate follow-up care
• Dissatisfaction
• Litigation/Bad publicity

(c) Eric A. Coleman, MD, MPH
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Barriers to Improving Transitions of Care
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Barriers to Care Coordination

• System level barriers
• Practitioner level barriers
• Patient level barriers

(c) Eric A. Coleman, MD, MPH
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System Level Barriers
(c) Eric A. Coleman, MD, MPH
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Practitioner Level Barriers

• Practitioners often have not practiced in
  settings where they transfer patients
• Sending practitioners may not communicate
  critical information to receiving practitioners
• Practitioners may not know the patient and his or
  her preferences for care
• Practitioners have no accountability

(c) Eric A. Coleman, MD, MPH
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Patient Level Barriers

• Patients assume that someone is in charge of
  coordinating care
• Patients (and caregivers) are often the only
  common thread weaving between care sites
• Yet they navigate the system with few tools or
  training to manage in this role

(c) Eric A. Coleman, MD, MPH
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AGS Position Statement

• Position 1
• Clinical professionals must prepare patients and
  their caregivers to receive care in the next
  setting and actively involve them in decisions
  related to the formulation and execution of the
  transitional care plan

Coleman EA, Boult C, The American Geriatrics
Society Health Care Systems Committee. J Am
Geriatr Soc 200351556-7.
(c) Eric A. Coleman, MD, MPH
12
AGS Position Statement

• Position 2
• Bidirectional communication between clinical
  professionals is essential to ensuring high
  quality transition care
• Position 3
• Develop policies that promote high quality
  transitional care

Coleman EA, Boult C, The American Geriatrics
Society Health Care Systems Committee. J Am
Geriatr Soc 200351556-7.
(c) Eric A. Coleman, MD, MPH
13
AGS Position Statement

• Position 4
• Education in transitional care should be provided
  to all health professionals involved in the
  transfer of patients across settings
• Position 5
• Research should be conducted to improve the
  process of transitional care

Coleman EA, Boult C, The American Geriatrics
Society Health Care Systems Committee. J Am
Geriatr Soc 200351556-7.
(c) Eric A. Coleman, MD, MPH
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Expectations for Both Sending and Receiving
Teams

• Shift from the concept of discharge to
  transfer with continuous management
• Begin transfer planning upon or before admission
• Incorporate patient/caregivers preferences into
  plan
• Identify a patients social support and function
  (how will this patient care for herself after
  transfer?)
• Collaborate with practitioners across settings to
  formulate and execute a common care plan.

(c) Eric A. Coleman, MD, MPH
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Expectations for the Sending Team

• The patient is stable for transfer
• The patient and caregiver understand the purpose
  of the transfer
• The patient and family understand their coverage
• The receiving institution is capable and prepared
• The care plan, orders, and a clinical summary
  precede the patients arrival
• The patient has a timely follow-up appointment

(c) Eric A. Coleman, MD, MPH
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Expectations for the Receiving Team

• Review the transfer forms, clinical summary, and
  orders prior to or upon the patients arrival.
• Incorporate the patient/caregivers goals and
  preferences into the care plan.
• Clarify discrepancies regarding the care plan,
  the patients status, or the patients medications

(c) Eric A. Coleman, MD, MPH
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What is the National Transitions of Care
Coalition?

• The National Transitions of Care Coalition was
  formed to bring together stakeholders from
  various care settings to address improving care
  coordination and communication when patients,
  especially older adults, leave one health care
  setting and move to another.

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Goals

• Identify issues and barriers to transitions
  across the continuum of care
• Evaluate appropriate referral criteria between
  levels of care
• Assess available technology, evidence based
  guidelines, medication reconciliation, and
  adherence gaps
• Establish disease state priorities for coalition
  focus, e.g., venous thromboembolism,
  diabetes/glycemic control, acute coronary
  syndrome, and stroke
• Develop tools, guidelines, and pathways for
  communication between patients, providers, and
  payers
• Develop awareness and resource implementation
  plans for coalition members to disseminate

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Advisory Task Force

• Academy of Managed Care Pharmacy
• American Association of Homes and Services for
  the Aging
• American College of Healthcare Executives
• American Geriatrics Society
• American Medical Directors Association
• American Medical Group Association
• American Society of Consultant Pharmacists
• American Society of Health-System Pharmacists
• American Society on Aging
• AXA Assistance, USA
• Case Management Society of America
• Consumers Advancing Patient Safety
• Health Services Advisory Group

• Institute of Healthcare Improvement
• Joint Commission Intl Center for Patient Safety
• The Joint Commission
• Liptiz Center for Integrated Health Care
• Mid-America Coalition on Health Care
• National Association of Directors of Nursing
  Administration Long Term Care
• National Association of Social Workers
• National Business Coalition on Health
• National Quality Forum
• National Case Management Network
• Predictive Health, LLC
• Society of Hospital Medicine
• The Joint Commission Disease-specific Care
  Certification
• URAC

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Raise NTOCC Awareness

• Information and tools available by stakeholder

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Working Groups
Education Awareness
Policy Advocacy
Tools Resources
NTOCC
Metrics Outcomes
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Education Awareness

• Working to address awareness and general
  knowledge about the problems associated with
  transitions of care and provide the necessary
  information to various stakeholders patients,
  caregivers, health care professionals, and
  government officials.

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Policy Advocacy

• Assessing ways to improve care through enhanced
  communication tools, collaborative partnership
  and evaluating the possibility of enhanced
  reimbursement for transitional care support and
  technical medical information shared between care
  settings.

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Tools Resources

• Identifying practical tools and resources that
  can be used by health care professionals, care
  givers and patients to improve communication in a
  consistent manner between care settings and
  reduce risk associated with care transitions.

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Metrics Outcomes

• To develop and adopt a framework for measuring
  transitional care.
• To recommend metrics or standards to demonstrate
  the impact of interventions on reducing risk
  associated with transitional care

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Case Studies for Discussion
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Case 1

• During a patients monthly follow-up appointment
  with the cardiologist, he informed the doctor
  that he was having trouble with one of his
  medications. The doctor asked which one. The
  patient said The patch, the nurse told me to put
  on a new one every day and now Im running out of
  places to put it! The physician had him undress
  and discovered that the man had over a two dozen
  patches on his body.

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Case 2

• An older man with atrial fibrillation who takes
  warfarin for stroke prophylaxis was hospitalized
  for pneumonia. His dose of warfarin was adjusted
  during the hospital stay and was not reduced to
  his usual dose prior to discharge. The new dose
  turned out to be double his usual dose and within
  two days he was rehospitalized with
  uncontrollable bleeding.